Healthcare Hospital discharge – what’s next?

Following a hospital stay, it is important for medical treatment to continue seamlessly and for patients to receive the best possible care. Various options are available depending on the patient’s specific situation.

In some cases, patients can return home directly – either without additional support or with the assistance of relatives or an outpatient care service, for example. In other cases, they may need temporary care in a short-term care facility or to a move to a nursing home. In the case of serious illnesses with no prospect of recovery, palliative care can be organized. If further medical treatment is required, follow-up treatment in a different hospital or a rehab clinic may be useful. 

The discharge day often comes around quicker than expected. For patients to be sufficiently prepared, it is important to organize a number of things at an early stage. Various specialists assist with organizational matters within the scope of discharge management. These include social services but also nursing staff and medical staff.

The staff in hospitals and rehab clinics are obliged to offer discharge management to people with statutory health insurance. The aim is for patients to be optimally cared for at home or in another suitable location after they have been discharged. Participation in the discharge management process is voluntary.

People with private health insurance have no legal entitlement to discharge management. However, hospital staff must provide them with all important information about their further care. 

Various specialists are involved in the discharge management process, including medical personnel, nursing staff and, in particular, social services. These are available as people to speak to during hospital stays.

Discharge management is based on what is known as a discharge plan. This outlines the support that will be needed following discharge, for example follow-up treatment or the organization of specific care. Patients are informed about all measures and receive comprehensive advice. Relatives or caregivers can also be involved in the consultation on request.

If it is necessary to apply for certain services for the period after the hospital stay, patients themselves or their authorized representatives are responsible for this. However, this is a challenging situation and it is often useful to get support. The specialists in the hospital are familiar with the necessary steps, can help with applications and can establish contact with the applicable bodies/authorities if required.

If necessary, the hospital will contact a patient’s health insurance fund or long-term care insurance fund. Written consent is required to this end, which can be revoked at any time.

After a stay in hospital, patients are not always immediately fit enough for everyday life. In some cases, medical rehabilitation (rehab) can support their recovery. Sometimes, help with everyday life is temporarily required – whether with domestic tasks, personal hygiene matters or medical measures. A range of support options is available to make aftercare easier, even for patients without a recognized care level.

The services must be applied for by patients themselves or their authorized representative. Hospital staff provide advice and support with organizational matters.

Medical rehabilitation (rehab)

Medical rehab is designed to specifically strengthen patients’ physical and mental health after an illness or surgery. It can help to alleviate symptoms, avoid complications and restore everyday independence.

If rehabilitation is required, the hospital’s social service team will help patients make an application and with organizational matters. Rehab can occur in an inpatient capacity in a rehab clinic or in an outpatient capacity at a facility near the patient’s home.

If rehab occurs straight after a hospital stay, it is referred to as follow-up treatment and should start within 2 weeks of discharge where possible. There are 2 options in this regard:

1. Rehab starts straight after the hospital stay. The patient is directly transferred to the rehab facility. There is no need to wait for the funding agency’s decision.
2. The patient is initially discharged home. Rehab starts as soon as the funding agency has approved the application.

Short-term care

Following a hospital stay, patients may be temporarily unable to look after themselves. In such cases, short-term care can be a useful solution. This involves patients being temporarily cared for in a care facility – usually for several days or weeks.

If a need for permanent care is found during the hospital stay, short-term care can also help by bridging the time it takes to organize care at home or find a care place.

Patients can receive up to 8 weeks of short-term care per year. The hospital’s social service team will again help with the application.

Transitional care

There are some situations where patients need further support following hospital treatment but it has not been possible to organize suitable nursing care. In such cases, patients can continue to be cared for in the hospital for a maximum of 10 days. This can be organized with the assistance of the social service team. Health insurance funds will cover the costs of this kind of transitional care if, for example, short-term care or medical rehab are not directly possible.

Home nursing

If patients need temporary support from an outpatient care service after their discharge, the doctors in the hospital can prescribe 7 days of home nursing.

Home nursing can include the following:

• Treatment care, such as wound care or administering medication
• Basic care, such as help washing or dressing
• Household assistance

Home help

Patients who are unable to perform domestic tasks following their discharge can sometimes be entitled to up to 4 weeks of home help. This assists them with cooking, cleaning or grocery shopping, for example. Home help must be applied for from a health insurance fund. The hospital’s social service team can help make an application. The doctors treating a patient can also certify the medical need. This certification should be included with the application. However, home help is only approved under certain conditions. For example, there must not be anyone else living in the household who could take over the domestic tasks to the necessary extent.

In some cases, it becomes clear even during their stay in hospital that patients will not be able to return to everyday life without longer term support. In such cases, it is particularly important to carefully plan the discharge. The necessary help and the need to apply for services must be assessed in good time.

Patients or their authorized representatives generally have to submit applications themselves. However, hospital social service teams can provide support and establish contact with the relevant authorities/bodies if necessary.

What to do in the event of a longer term need for care

If longer term care is likely to be required, an application for a care level should be made to the responsible long-term care insurance fund as soon as possible. The social service team can provide support in this regard. Once the application has been received, the long-term care insurance fund will commission the Medical Review Board to conduct an assessment. During this, specially trained care professionals determine whether there is a need for care and which care level can be assigned.

In urgent cases, an emergency application for a care level can be made. This could be necessary if care cannot be secured following discharge from the hospital or rehab facility, for example. Within the scope of an emergency application, an abridged report is first created. The full assessment is then conducted at a later time.

Sometimes, the existing care level is no longer high enough. If the increased need for care is likely to persist for longer, a higher care grade can be applied for. Again, an emergency application can be submitted in urgent cases.

Once an application for a care grade has been submitted, patients are entitled to care advice. This can also be provided in the hospital. The long-term care insurance funds or on-site care advice services are the points of contact for this. 

The details of various care advice services near you can be found in the Center for Quality in Care (Zentrum für Qualität in der Pflege – ZQP) database.

Privately insured individuals and their family caregivers can receive advice from Compass private Pflegeberatung gGmbH on behalf of their private insurance company.

What support options are available in the case of a longer term need for care?

Several outpatient services are available with regard to nursing care. For example, care or support services can come to patients’ homes and provide assistance in areas such as personal hygiene, administering medication, wound care and even domestic tasks and the structuring of everyday life. The aim is enable patients to lead as independent a life as possible at home.

If home care does not suffice or is not desired, moving the patient into a nursing home can be a suitable alternative. This offers 24/7 care and support. Semi-residential care, such as day care, is also possible.

In the case of a longer term need for care, various questions need to be answered. These include:

• Can support and care be provided at home?
• Can relatives provide the care or does a care or support service need to be organized?
• Is it not or no longer possible to provide the care at home independently or with the help of relatives so semi-residential care or a move to a nursing home is required?
• Is it necessary to apply for care aids such as a wheeled walker or a care bed?

It is useful if the care recipient and their relatives answer these questions together and obtain care advice at an early stage. Hospital social service teams can help with the search for a suitable care facility.

Nursing homes differ in terms of their location, their equipment and amenities and the nursing and therapeutic services they offer. It is therefore useful for relatives to help with the search for a suitable nursing home. When looking last minute in particular, it is often hard to find a place.

Further information about care provision in Germany can be found in the article Care provision for long-term care recipients – who does what?

Pflegewegweiser NRW provides practical support in the form of a checklist for the first steps in the case of a need for care.

What support is available if intensive medical care is required?

People who are severely ill and in great need of medical care – for example artificial ventilation – do not have to stay in hospital to receive this thanks to the concept of out-of-hospital intensive care. This is subject to specially trained nursing staff being on site at all times as it is not possible to rule out the possibility of life-threatening situations.

In practice, however, it is often difficult to find a suitable care service. Obtaining a prescription is also an arduous process. Doctors in the hospital can issue an initial prescription that covers up to 7 days after a patient’s discharge. After this, a follow-on prescription is required from a specially authorized doctor in a private medical practice.

Further information about out-of-hospital intensive care and how this is prescribed can be found in our article on this topic.

What options exist in the case of serious illness with no prospect of recovery?

If it becomes apparent during a stay in hospital that it is no longer possible for a patient to recover from a severe illness, the focus turns to palliative care. This is designed to alleviate symptoms such as pain, shortness of breath or anxiety and to preserve the patient’s quality of life insofar as possible.

Patients can often receive care at home, for example in the form of general outpatient palliative care (GOPC). If this support does not suffice, specialized outpatient palliative care (SOPC) can be considered. The SOPC team is made up of nursing and medical specialists and supports seriously ill people at home and in care facilities – including at night and on weekends. 

If care at home is no longer possible or desired, an inpatient hospice may be an alternative. These facilities support the critically or terminally ill in the end-of-life phase.

The hospital’s social service team can help organize palliative care. Health insurance funds generally cover the costs.

The hospice and palliative care information (“Wegweiser Hospiz- und Palliativversorgung”) database provided by the German Association for Palliative Medicine (Deutsche Gesellschaft für Palliativmedizin e.V.) offers a comprehensive overview of services and facilities throughout Germany.

If necessary, doctors in the hospital can prescribe certain services for the first few days after a patient’s discharge.

Medication

There are two ways to obtain medication after being discharged from hospital. Firstly, doctors in the hospital can prescribe medication for up to 7 days after the discharge. The prescription must be presented at a pharmacy following the discharge. Secondly, the required medication can be taken with patients directly, for example if discharged just before the weekend or a bank holiday. However, this is only possible for the amount of medication required for “bridging purposes”.

It is advisable to arrange an appointment with a GP in good time in order to obtain further prescriptions.

Dressings, therapeutic services and medical aids

Some prescriptions are intended to further support recovery following discharge from hospital and to promote mobility and independence. The hospital can issue an initial prescription for the period directly after discharge.

Examples of prescribable services include: 

• Dressings, for example for wounds
• Therapeutic services such as physiotherapy or occupational therapy
• Medical aids such as a wheelchair or compression stockings

Sociotherapy

In some cases, people with mental illnesses can be prescribed sociotherapy upon discharge from a hospital. Sociotherapy is intended to help people cope better with everyday life. Therapists help them keep appointments and adhere to treatments, for example.

Digital health applications (DiGA)

Digital health applications can also be part of the aftercare process following a stay in hospital. These are apps or online programs that can be medically prescribed. They provide support in relation to certain medical conditions, such as chronic pain or mental problems.

On the day of discharge, patients receive important documents. Documents like the doctor’s letter or the medication treatment plan contain medical information that is important for patients themselves, doctors providing follow-on care or even health insurance funds. Some documents are provided directly in hard-copy format while others are provided electronically.

Doctor’s letter

Upon discharge, patients generally receive a preliminary doctors’ letter. They should take this with them to their first appointment with their general practitioner so that the treatment can be continued in a coordinated manner.

The final doctor’s letter is retrospectively sent by post. This is automatically forwarded to the referring doctor unless otherwise specified. However, patients are entitled to determine who the letter should be sent to. Doctors in the hospital can also directly transmit the letter electronically to the medical practice providing further treatment (eDoctors’ letter).

The information provided in the doctor’s letter includes:

• medical history
• medical conditions (diagnoses)
• Treatments performed
• treatment course and findings
• prescribed medication
• recommendations for further treatment

The doctor’s letter also shows the contact details of the people in the hospital who should be consulted if questions arise following discharge.

To name diagnoses in a standardized manner, they are encrypted by alphanumeric codes. The ICD code search on gesund.bund.de provides you with clear and simple explanations of your diagnoses.

Medication treatment plan

Previously used medication is often changed or supplemented with new medication during a stay in hospital. An up-to-date medication treatment plan is provided with the doctor’s letter on the day of discharge.

The medication treatment plan includes:

• an overview of all current medication
• the dosage and time at which medication should be taken
• the planned time for which the medication will be taken
• if necessary, information about potential interactions

The medication treatment plan can also be directly stored on and accessed from the medical data card in electronic format (eMP).

Sick leave notice (sick note)

If patients are not fit for work upon discharge, the doctors in the hospital can issue a sick note for up to 7 days. This is usually transmitted electronically to the health insurance fund (eAU). If patients are still not fit for work at the end of this period, their registered doctor must issue a follow-on note.

Certificate of admission

A certificate of admission (known as a “Liegebescheinigung” in German) proves that a person was not fit to work while in hospital. This is also important for health insurance funds if people receive or wish to apply for sickness benefit. Like the sick leave notice, it is now generally provided electronically.

Transport certificate

Relatives or acquaintances are not always available to collect people on the day they are discharged from hospital. However, this alone is not a reason for a health insurance fund to cover the travel costs of using a taxi or being transported in an ambulance. For journeys to be covered by insurance, they must be required for medical reasons. This is determined by the doctor in the hospital, who will issue a transport certificate if necessary. Such journeys are generally subject to a co-payment.

With good planning, discharge from hospital can run smoothly and optimum further treatment can be ensured. For a successful transition, you should answer several questions in advance:

• Is follow-up treatment or medical rehabilitation (rehab) planned?
  If the answer is yes, an application should be made in good time. Hospital staff will help with the application process and organizational matters.
• How will I get home, to a care facility or to a place for further treatment?
  Is it necessary to arrange patient transportation or can you travel home independently? You can also ask nursing staff on the ward to call you a taxi.
• Do I need medical aids? 
  Examples include walking aids, a wheelchair or compression stockings. The hospital staff can issue a prescription for up to 7 days if necessary.
• Do I need a sick leave notice (sick note)?
  If the answer is yes, doctors can give you a sick note for up to 7 days after your discharge.
• Have I got the medication I need for the next few days or received a prescription for it?
  A timely supply of medication is important for seamlessly continuing treatment.
• Are other check-ups or follow-up examinations required?
  If the answer is yes, clarify when and where these will take place.
• Have I arranged an appointment with my GP practice or a specialist practice after my discharge?
• Do I need help with everyday life once discharged?
  If support is needed with domestic tasks, grocery shopping or medical appointments, this should be planned prior to discharge.

Do I need additional support with everyday life or care?

If you need permanent support with everyday life, you should answer the following questions:

• Do I already have a care level?If not, has one been applied for?
  A care level is needed to receive benefits under long-term care insurance.
• Have I clarified the cost of the care?
  Financing should be discussed in advance with the long-term-care insurance fund or other authorities such as the social welfare office or employers’ liability insurance associations.
• Has an outpatient care service been organized or a place in my desired care facility been secured?
  If outpatient or inpatient care is needed, accommodation should be organized in good time. Discharge management helps with this process.
• Has the care service or nursing home been notified of when I will be discharged?
• Is it necessary to arrange further forms of assistance?
  Examples of such assistance could include “meals on wheels” or day care.

What do I need to consider on the day of discharge?

On the day of discharge, you should have all important documents and information:

• Have I been given all necessary documents?
  These include the doctor’s letter and medication treatment plan as well as any prescriptions.
• Have I understood the instructions on the medication treatment plan about taking the medication?
  If anything is still unclear, ask.
• Has a discharge consultation taken place?
  If not, one should be requested. This can be used to clear up any final questions about further treatment.
• Have I noted who to contact if I have queries?
  It is important to know who you can turn to if any questions arise following your discharge.